Nurse Case Manager - Senior Care Options - Lawrence/Haverhill

apartment Fallon Health location_onLawrence, MA 01843, US

Overview

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team. Responsibilities may include conducting in home face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM may conduct assessments and may determine the number of hours’ members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines. The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction.

Responsibilities

Note: Job Responsibilities may vary depending upon the member’s Fallon Health Product

Member Assessment, Education, and Advocacy

Telephonically assesses and case manages a member panel

May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member’s clinical/functional status to identify ongoing special conditions and develops and implements an individualized,coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome

Performs medication reconciliations

Performs Care Transitions Assessments – per Program and product line processes

Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member’s medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category

Maintains up to date knowledge of Program and product line benefits, Plan Evidence of Coverage details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights

Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other external partners

Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives

Assesses the Member’s knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self- manage his or her health needs, social needs or behavioral health needs

Collaborates with appropriate team members to ensure health education/disease management information is provided as identified

Collaborates with the interdisciplinary team in identifying and addressing high risk members

Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes such initiatives involving Key Metrics outreach

Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team

Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information

Supports Quality and Ad-Hoc campaigns

Care Coordination and Collaboration

Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved

documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives

With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Navigator to ensure the member approves their care plan

Manages NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers and others involved/authorized in the member’s care

Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member’s care

Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’s health care goals and needs

Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process

Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining the focus of the Member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care

Actively participates in clinical rounds

Provider Partnerships and Collaboration

May attend in person care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable.

Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met

Regulatory Requirements – Actions and Oversight

Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes

Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams

Performs other responsibilities as assigned by the Manager/designee

Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee

Qualifications

Education:

Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred.

License:

Active, unrestricted license as a Registered Nurse in Massachusetts

Certification:

Certification in Case Management strongly desired

Other:

Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation

Experience:

• 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required• Understanding of Hospitalization experiences and the impacts and needs after facility discharge required• Experience working face to face with members and providers preferred• Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required• Home Health Care experience preferred• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need working in partnership with a care team preferred• Familiarity with NCQA case management requirements preferred

Performance Requirements including but not limited to:• Excellent communication and interpersonal skills with members and providers via telephone and in person• Exceptional customer service skills and willingness to assist ensuring timely resolution• Excellent organizational skills and ability to multi-task• Appreciation and adherence to policy and process requirements• Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education• Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties• Willingness to learn insurance regulatory and accreditation requirements• Knowledgeable about software systems including but not limited to Microsoft Office Products – Excel, Outlook, and Word • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables• Accurate and timely data entry• Effective case management and care coordination skills and the ability to assess a member’s activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member’s need • Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver

Competencies:

• Demonstrates commitment to the Fallon Health Mission, Values, and Vision• Specific competencies essential to this position:

Problem Solving
- Asks good questions
- Critical thinking skills; looks beyond the obvious
Adaptability
- Handles day to day work challenges confidently
- Willing and able to adjust to multiple demands, shifing priorities, ambiguity, and rapid change
- Demonstrates flexibility
Written Communication
- Is able to write clearly and succinctly in a variety of communication settings and styles.

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $88,000 - $95,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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The professional registered nurse is responsible for the planning, delivery and management of patient/family centered care utilizing the nursing process and adhering to the standards of nursing practice embedded in research, evidence based practice and/or best practices. The professional registered nurse at Tufts Medical Center provides clinical excellence, which fosters and supports an environment central to our patient and family centered model of care. Job Description Minimum Qualifications: 1. Registered Nurse (RN) license. 2. Basic Life Support (BLS) certification. 3. Certifications (i.e. ACLS, PALS) relevant to the department and type of care being provided may be required. Preferred Qualifications: 1. Bachelor of Science in Nursing (BSN) 2. Specialty Nursing certifications. Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned. 1.Utilizes theoretical and evidence-based knowledge in partnering with patients and their families to assess, plan, implement and evaluate age appropriate care. 2. Assesses and collaborates with patient, family/significant others and other disciplines to: Identify expected outcomes based on synthesis of data and diagnosis; and identify cultural needs (i.e. language, etc) to develop a care plan that enhances the health care experience. 3. Plans and develops: Individualized outcomes-based care plans incorporating the patient and family’s readiness and barrier to learning; Orchestrates and validates a plan of care for each shift; Initiates interdisciplinary patient/family meetings to facilitate communication regarding the plan of care; Communicates and coordinates the patients discharge plan utilizing unit-based and community resources to ensure a seamless transition for the patient and their family; Ensures the plan of care utilizes principles and concepts of project, organizational or systems management. 4. Implements: The plan in a safe and timely manner; Documents the implementation and any modifications, including changes or omissions, of the identified plan; Collaborates with nursing colleagues and others to implement the plan; Utilizes evidence-based interventions and treatments specific to the diagnosis or problem; Provides and coordinates health teaching which is required by individuals, families and groups to maintain an optimal level of health; Documents per hospital and regulatory requirements/policies, all aspects of care, including but not limited to, treatments/procedures performed and patient response. 5. Evaluates: The effectiveness of the planned strategies in relation to patient responses and the attainment of expected outcomes and knowledge; Uses the evaluation process to update the plan of care as dictated by the patient response and/or if desired outcomes have not been achieved. 6. Demonstrates and applies the skill and judgement necessary to implement the nursing plan of care, nursing interventions and procedures necessary for the care of the patient and family based upon critical thinking skills and a spirit of inquiry. The plan of care is: Evidence based and utilizes research when appropriate; Incorporates new knowledge and strategies to initiate change in nursing care practices; Demonstrates the knowledge and skills necessary to provide age appropriate culturally and ethnically sensitive care to all patients and families. 7. Performs procedures and treatments using nursing knowledge and judgment, according to established unit/practice area guidelines and professional standards. 8. Safely administers and assesses the patient response to medication utilizing essential knowledge of pharmacology and Hospital and Department Standards of Care. 9. Maintains clinical competency with respect to technology and utilizes equipment in a safe manner. 10. Performs as an advocate and as an educator for patients and families. 11. Provides high quality in an efficient and a safe manner. The professional nurse utilizes data trends to support and improve clinical practice. 12. Participates in hospital and/or unit based patient safety and quality activities and uses principles to support and improve patient outcomes (unit-based, hospital-wide, The Joint Commission, NPSGs, NDNQI, Patient First and other local, state and federal patient safety initiatives. 13. Participates in performance improvement activities through data collection, analysis and evaluation. 14. Champions quality, safety, regulatory, and patient-family satisfaction. 15. Facilitates cooperative and collaborative relationships among the various disciplines and departments to ensure effective quality patient care delivery and to create a positive and professional work environment. Supports collaboration with nursing colleagues and other disciplines to implement plan of care by participation in nursing, physician, and case management reporting rounds. 16. Delegates responsibilities to others with an understanding of their roles, knowledge and capabilities 17. Influences others to achieve Service Excellence by: Establishing a climate for optimal patient care, mutually supportive collegial relationships, and professional development; Treating both internal and external customers with courtesy, respect and caring behavior; Promoting a safe, clean, therapeutic environment for patients, families and staff; Acknowledging cultural differences that exist among staff and patients; Identifying customer service needs on the unit; Presenting self in a professional and calm manner; Providing responsible and efficient use of resources. 18. Participates in professional development and lifelong learning activities that assist in developing and maintaining their continuing competence, enhance their professional practice and support achievement of their career goals including: Maintaining current licensure and adheres to the Massachusetts Nurse Practice Act; Assuming responsibility for participating in educational opportunities to support and meet clinical competency requirements; Seeking out educational and professional resources; Developing professionally as a self-directed, motivated learner; Seeking out advanced certification opportunities and ongoing education opportunities; Precepting and mentoring newly hired staff and nursing students; Investigating available technology and resources to apply evidence based practice and research into daily professional activities; Promoting leadership at the bedside as a delegator, collaborator, facilitator, and communicator; and Promoting unit and organizational growth through a shared governance model. 19. May assume charge nurse functions in collaboration with unit leadership; 20. Facilitates communication by: Seeking and sharing job-related information that supports a culture of respect and responsibility; Assuming responsibility and ownership for professional conduct; Accepting responsibility for positive and productive communication skills; Attending and actively participating in staff meetings (when unable to attend, accepts responsibility for reading staff meeting minutes); and Accepting responsibility for reading emails to keep current with unit and hospital based information. Physical Requirements: 1. Prolonged, extensive, or considerable standing/walking. 2. Lifts, positions, pushes and/or transfer patients and equipment. 3. Considerable reaching, stooping, bending, kneeling, crouching. 4. Frequent exposure to hazardous chemicals, sick patients, bodily substances, noise and possible exposure to radiation, lasers, electric shock, etc. 5. Regularly exposed to the risk of bloodborne diseases and other transmissible infections. 6. Contact with patients under wide variety of circumstances. 7. Subject to varying and unpredictable situations. 8. Handle emergency and crisis situations. 9. Subjected to irregular hours. 10. May have contact with hazardous materials. Skills & Abilities: 1. Possesses and applies the skills and knowledge necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process. 2. Ability to provide care for a designated group of patients according to unit guidelines and hospital policies, procedures and protocols. 3. Has the skills and knowledge to provide care to the age groups of the population served including: Knowledge of growth and development; Ability to interpret age specific data and response to care; and Provide age appropriate communication. At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day. The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals. Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it. Pay Range : $41.76 - $68.89

OB/GYN

Oncology

Other

Registered Nurse, RN - GYN Oncology

apartment Tufts Medicine location_onBoston, MA

Registered Nurse, RN - GYN Oncology Tufts Medical Center is recognized by the ANCC Magnet Recognition Program® for excellence in nursing. Magnet® recognition is the highest and most prestigious credential a health care organization can achieve for nursing excellence and quality patient care. Magnet® recognition signals to nurses that the organization is committed to nursing. The nurses at Tufts Medical Center are integral to everything we do. They are often the ones patients interact with first, and sometimes the ones they interact with the most. It’s a critically important role, so our nurses are well-supported, well-respected, and very well-appreciated! There’s an intensity and a pace to be embraced. You will have responsibility and accountability the minute you pull on the scrubs. You need to be the kind of person who gives everything you've got. Our patients deserve the best. Our nurses give it to them. The Gyn Oncology Department is a high-acuity ambulatory unit that specializes in providing the following care services: Performing triage on existing and newly referred GYN Oncology patients including and not limited to symptom management, medication questions, side effects, plan evaluation and explanation, and emotional support. Accessing patient’s ports, placing IV’s and lab draws prior to visits, scans or ED transfers. Interpreting lab results and discussing lab results with patients when appropriate. Observing, monitoring and reporting the patient’s condition and progress before during or after treatment. Assessing patient’s tolerance and side effects when receiving chemotherapy or immune therapy. Educating patients, families and caregivers regarding disease, progression, treatment, side effects and symptom management. Preparing patients for surgery with education on care before, during and after surgery. Evaluating healthcare needs and goals for treatment Connecting patients with resources such as social work, nutrition, palliative care, therapeutic modalities, etc. Maintain communication and coordinate interdisciplinary care with all in house and outside providers to support the patient’s needs. Supporting patients after diagnosis and treatment into surveillance and survivorship programs. Assisting the provider during clinic appointments with procedures, prescriptions refills, ordering scans, labs, etc. Position/Job Title: 32 hours per week, 7A-3P No call or weekends Home Department: GYN Oncology Job Profile Summary This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Clinical Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed. Provides professional nursing care to patients. Requires a nursing license. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems. Job Overview The professional registered nurse possesses and applies the skills and knowledge necessary for the delivery and management of patient care from admission through discharge. The professional registered nurse is knowledgeable of current trends in healthcare including but not limited to advances in technology, pharmacology, treatment care modalities, quality and patient safety. The professional registered nurse serves as a patient and family advocate while facilitating a cooperative and collaborative environment among all health care providers. The professional registered nurse is responsible for the planning, delivery and management of patient/family centered care utilizing the nursing process and adhering to the standards of nursing practice embedded in research, evidence based practice and/or best practices. The professional registered nurse at Tufts Medical Center provides clinical excellence, which fosters and supports an environment central to our patient and family centered model of care. Minimum Qualifications: 1. Registered Nurse (RN) license. 2. Basic Life Support (BLS) certification. Preferred Qualifications: 1. Bachelor of Science in Nursing (BSN) 2. Specialty Nursing certifications. At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day. The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals. Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it. Pay Range : $41.76 - $68.89